This is the third installment of our series on the ‘care and feeding’ of the injured lumbar disc. In Part 1 we discussed the structural pathology (the broken stuff) and in Part 2 we started a discussion of the functional pathology (why stuff broke). Today, we’ll continue the functional discussion assuming you’ve done some pre-reading or have an understanding of the Joint By Joint Approach. If you don’t, follow the link and brush up. Also, these approaches and the exercises associated with each stage of the rehab process are represented in the library of detailed functional rehab exercise here at MyRehabExercise.com. You can’t use them to help teach your patients and clients unless you’re a member. Membership is inexpensive ($9.99/mo), 30 day trial for $1 and you can discontinue service anytime. Follow the links to the right to sign up.
If you don’t have an office set up to instruct your clients or patients in rehab exercise, or if you just don’t feel comfortable customizing the exercise Rx yet for disc injury, check out FixYourOwnBack.com. There, you can just refer your patients or clients with disc injury, disc bulge, herniation, sciatica and for $9.99/mo they can receive the self-help education and rehab Rx that is being discussed in this blog series re: management of the lumbar disc injury.
The Plan–”Plan the work, then work The Plan”
Once we have an injured lumbar disc, The Plan (as it’s referred to on FixYourOwnBack.com) is as follows:
- Stop faulty movements and postures that “pull the scab off” of the healing disc
- Learn disc “First Aid” using McKenzie methods to assist in healing and control pain
- Use McGill’s Big 3 and DNS methods to stabilize the lumbar spine
- Improve mobility in the T-spine and hips to spare the spine
- Use FMS-based corrections to integrate stability and mobility achieved in #3 and 4 above into long term sustainable movement patterns
- Improve strength in the muscles necessary to perform #5 above
- Improve agility in those sustainable movement patterns to help with resilience when life throws a curve
- Incorporate sport specific skills to help manage disc injury and recurrence
This flow pattern has been put together based on my clinical experience working with disc injuries daily and by studying with the rehab schools of thought mentioned above. Credit for much of the overall flow is from Stu McGill’s
flow mentioned in his excellent books and DVDs.
I have added to that flow pattern as I’ve added tools from the sources above. Most readers of this blog are already familiar with McGill’s Big 3, but perhaps not to DNS
. I am waist deep in my training in that school of thought but owe my introduction to the Prague methods to my mentor, Dr. Craig Liebenson
Craig will be hosting a DNS instructional course in Phoenix in November
as well as several other introductory courses in the US in 2012, if you’d like to get started with adding these innovative and effective approaches. Let’s segue now to the next area of focus that I often see benefit for with disc patients…mobility limitations in the thoracic spine and hips.
The Stiff Upper Back
Chairs are often the culprits
that steal valuable mobility from the t-spine and hips. Prolonged sitting posture often results in slumping, exaggerating the kyphotic curve of the thoracic region. Adaptational shortening of the surrounding muscles and tissues results in loss of thoracic extension and rotation
. Passive methods can be used to help restore that movement like foam roll and lacrosse ball mobilizations in the gym, or bodywork in the clinic or studio. Active methods
, in my experience, take less time
to restore this mobility and tend to last longer
. Search YouTube and you’ll find dozens of exercises that help with this area, but I like the Modified Sphinx
, Thoracic Rotation
and Sidelying Thoracic Extension + Rotation
exercises and they’re on the website at MyRehabExercise.com
Modified Sphinx-MyRehab members can click here to view the video
The Creaky Hips
Remember, the Joint by Joint Approach views problems in the stable joint complex areas to be due to limitations in the mobility of surrounding more mobility-oriented joint complexes. Below the lumbar area are the femoro-acetabular joints…the hips…which are high pay off areas for long term improvement of disc injury. These big ball and socket joints beg for movement that our chairs slowly suck out of us daily. The 2 planes of movement that are typically lost are extension and abduction, as those muscle groups shorten from lack of frequent length changes. Shortening of the resting length of the hip flexors results in mechanical and neurological side effects.
Mechanical Effect of Shortened Hip Flexors:
As the shortened flexors’ insertion onto the lesser trochanter persists, the femur shifts anteriorly in the acetabulum. When that individual squats deeply, the acetabular labrum gets munched and sometimes the repetitive loading of this imbalanced hip into deep flexion can result in bony changes now referred to as femoral acetabular impingement (FAI). For more info on FAI, check out this link to Craig Liebenson’s blog. Learning how to test for this is helpful, as an Xray can point to whether that patient should be in an orthopedist’s office. However, all anterior hip pain is NOT FAI, and the condition starts as a soft tissue issue. Catching it early in the progression means you can head off not only a hip replacement years later but also the well-meaning FAI surgery!
Neurological Effects of Shortened Hip Flexors:
Charles Scott Sherrington’s Law of Reciprocal Innervation won him a Nobel Prize in 1932 for describing the neurological relationships between agonist and antagonist muscle groups. Stated simply, when a muscle contracts, its antagonist on the other side of the joint is reflexively relaxed to allow joint movement to occur. Several decades later, Czech neurologist Vladimir Janda coined a corollary to Sherrington’s Law which states that when a muscle’s resting length has been shortened, it’s antagonist will be reflexively inhibited. Around the hip joint, the tight hip flexors inhibit the large muscles of the buttock…the glute max and the glute med. This condition in the hips has been referred to in Janda circles as part of the Lower Cross Syndrome, and years later by Stu McGill as ‘gluteal amnesia’.
What we then see in the clinic is pain in the smaller muscles of the buttock, namely the gluteus minimus, piriformis and TFL>ITB. Pain in these muscles then represents an overuse syndromeas the smaller muscles are re-tasked to share the load the glute max/med should be bearing. While manual therapies (massage, myofascial release, Graston, Stecco, foam rolling ) are helpful in reducing the pain in these areas, the relief is temporary unless you address the functional causes.Now that you know this, if you’re in the business in your clinic of mining this repeat business for fun and profit, then you’re part of the problem. Either learn how to correct the functional imbalances or refer to someone who does after you perform the worthy service of helping to manage your patient/client’s pain! To improve mobility in the hips, flexor stretches (lunges) are helpful and Goblet Squats are the bomb for opening up the medial joint capsule. Many disc patients though, can’t manage the deep squat position of the Goblet without loss of the lumbar lordosis and resultant stress of the injured disc. For those folks we have the Tactical Frog to help open the hips a bit before progressing to the Goblet.
Tactical Frog-MyRehab members can click to view the video.
Our next step in rehabbing the disc injury then moves to re-training the hip and spine to function well together. In some circles I’ve heard this referred to as ‘de-coupling’ the hips from the spine. I see it more as integrating the stable spine to the moving hip
. We use the sternal crunch + abdominal breathing pattern
to get the internal spine stabilization system working, then add a high complexity/low load exercise (Dead Bugs
) on top to groove the pattern. After that I really like the Leg Lowering progressions from the FMS
corrections to add load. We then borrow a page from Gary Gray and stand the patient up and have them to practice standing hip flexor endurance. The hip flexor endurance test attributed to Shirley Sahrmann was described by Mike Boyle in this paper
and the procedure is below.
- In single leg stance, pull one knee to the chest and release.
- Observe for failure in ability to maintain >90 degrees of hip flexion for 15 sec.
- Is there cramping in the TFL?
- Observe for posterior lean, rounding in the spine or lateral tilt of the pelvis
As the psoas group and the iliacus are the only 2 hip flexors that can flex the hip beyond 90 degrees, the observations above indicate weakness of those muscles if those signs are present. I’ve found that the test can be effectively used as an exercise by cueing the patient to avoid the above faults and work to increase endurance in the single leg stance from 15-30 seconds. We bring all of the cues together from all of the previous work to get all of the parts working together well…ribs down, be long through the spine, pinch a quarter in the butt cheeks, belly breathe. I also cue them to place a hand lightly on the lumbar spine to get biofeedback for spine movement and one hand over the lower ribs looking for flare of the ribs. Your target is to keep the knee over 90 degrees and have NO movement in the lumbar spine.
FixYourOwnBack members can find this as part of Chapter 5-Integrating Stability and Mobility
Once the hips are dialed in, our disc patient can start having more fun! Transverse plane movement progressions like rolling>hard rolling>chops/lifts>Pallof presses can begin the journey to strength training and we incorporate those into the program at FixYourOwnBack.com.
Soft Rolling-Lower, From MyRehabExercise video tutorial library
Hard Rolling--from MyRehabExercise video tutorial library
Tall 1/2 Kneeling Chops--from MyRehabExercise video tutorial library
Pallof Presses--from FixYourOwnBack video tutorial library
Since many folks pursue that strength training in a standard “big box” type gym, we take time to instruct them about specific equipment and exercises to avoid. Those that are have aspirations toward some of the bodyweight “boot camp” type programs need caution on some of the excellent exercises like burpees, man-makers and mountain climbers. We’ll save that info for the next post here at MyRehabExercise.com.
As a reminder, this progression plan outlined in these posts is already laid out as a self-help membership site at FixYourOwnBack.com. Membership is only $9.99/month, less than the co-pay in most insurance plans, and no contract means your patients or clients can quit when they’ve reached their goals.
For those readers already saavy
to these types of functional exercises and who want more control over the exercise Rx, consider membership to MyRehabExercise.com.
There you’ll find a library of detailed functional rehab exercise tutorial videos you can send to you patients and clients via email to better tailor their progress to your professional assessments. Be well!
is a sister site with…